Monday, September 26, 2016

Welcome, to our special 100th blog as a team. I would like to take this opportunity to thank the Journal, ATSA, the blogging team [thanks David and Jon] and all contributors, as well as everyone who reads the blogs. Here's to the next 100 blogs. Thanks. - Kieran

It was a little over two
years ago that Robin Wilson handed over the reins of the SAJRT Blog to Kieran,
who along with David and Jon have continued to shine a light on the challenges
of mitigating sexual harm.Since then,
this blog marks number 100; so we thought it would be a good time to reflect on
‘the big picture,’ if you will – how the etiologies, treatment, management, and
prevention of sexual harm are a multifaceted, interdisciplinary matter.The links in this special, 100th blog are to
selected SAJRT blogs that have been published over the last two years.

Sexual harm is often
discussed in the stark, polarizing terms of ‘victim’ and ‘offender’ (abuser or perpetrator),
which is problematic for many reasons.Not only does every incident of sexual harm reach far beyond the two
individuals involved, the language
of sexual harm tends to reduce two people to their regrettable ‘roles’ – a
“victim” of sexual abuse, or a “sex
offender.” At a minimum, sexual harm
involves victims, perpetrators, families, friends, peers, institutions,
and communities.Broadly speaking,
sexual harm is never about just two people – it involves all of society, and therefore
prevention
requires public
engagement on a global
level.

It’s important to recognise
that understanding and mitigating sexual harm requires social policies that
draw on perspectives from (at least) psychology, sociology, criminology, health
(mental-physical-public health), and even economics. Each of these disciplines deserve a place at
any table where sexual harm is discussed. While some professionals are concerned
primarily with perpetrators of sexual harm in clinical and treatment terms, colleagues
in other areas may be more involved with victims, or the economics of
treatment, maybe the practicalities of housing sex offenders, or perhaps the political
ramifications of sexual offending.Although
these are somewhat different matters, they are all valid perspectives on the
same broad issues – multiple stakeholders, nationally and internationally, coming
together, sharing information, developing a more complete picture of sexual
abuse, enabling us to provide the best responses – preventative or reactive. Multiple
disciplines and professional perspectives all bring something different, and
important, to the table - they open our eyes to different ways of developing
and applying
best practices to the effective
intervention, treatment,
and prevention
of sexual harm.

Friday, September 16, 2016

The elephant in the closet in the treatment and supervision of people who have sexually abused is the voice of the clients themselves. The service user (or in this instance the person who has sexually abused) is at the center of the work that we do, but there perspectives and views of the services that they are subject to are not always present. We need to hear the views, attitudes and perspectives of the service user regarding the work that they are part of (that is listening to the service user voice); we do it in health, business, marketing and other areas of life, but why not sex offender treatment and management? There is an inherent view in some sectors of our field that people who have sexually abused are manipulative, deceptive, and therefore not trustworthy; which means that their views of the service they are part of is unreliable at best and suspect at worst. This is a real issue when one considers that people who have sexually abused are the users of multiple services including counseling, psychology, health, social services, and the criminal justice system. Other users of these services often have mechanisms through which to have their voices heard and participate in the processes that have an impact on their lives. This might take the form of client advisory councils, satisfaction surveys, or feedback-informed treatment.

One has to wonder why a lack of a coherent client/service-user voice is uncommon for one population (e.g., people who have abused) and not another (e.g., people in substance abuse treatment). Perhaps more importantly, do professionals all too often come to think of treatment of people who have sexually abused as something we do to and on our clients rather than with and for them (Miller & Rollnick, 2013)? Do we dictate that treatment must take place in the fashion that we want or one that is most effective for the client? How do we know when we are meeting both the need and responsivity principles in a way that is meaningful for the client? Or is it that we are just as susceptible to bias, misperception, stereotypes and misunderstandings as the public and politicians? Do you “fall in line” with biases that we argue against? This is an international dilemma, as this problematic approach to the person who has abused as a disenfranchised and unrecognized service user is not just a western problem. Let’s explore this further.

A discussion of the role of Volunteer Probation Officers (VPOs) recently took place at the United Nations Asia and Far East Institute in Tokyo. VPO’s are typically older and well-established citizens who mentor young offenders, from around Japan. The role of the VPO’s is to assist the young offenders with their behavior, actions, and plans for the future. It is a system designed to provide support and bring about hope and accountability, even as the young offenders can be at risk for disengaging and participating minimally. During the panel discussion, one attendee asked what regrets the VPOs had about their work. The answers were as heart-rending as they were similar; each participant described a time when they had listened more effectively, worked harder to understand the young person, or helped them to achieve the goals that were meaningful to them and not just the legal system.

On their own, these responses are unsurprising, and resemble other human situations where desired outcomes aren’t achieved, such as parents whose children haven’t lived to their full potential or whose lives have ended early. What was striking among the VPOs was what was not said. Reflecting on their failures, no VPO regretted that their young charges had not gotten the diagnostic clarity, effective medication regimes, or the correct empirically supported protocols they needed. In further discussion of this fact, the VPOs acknowledged, as do all professionals, that diagnostic and treatment considerations are vital to success, but that the prevention of failure can reside in the moment-by-moment interactions that all professionals have with their clients.

Likewise, as we go to press with this blog, the Australian Psychological Society has just issued an apology to the indigenous peoples of that country. They state:

To demonstrate our genuine commitment to this apology, we intend to pursue a different way of working with Aboriginal and Torres Strait Islander people that will be characterized by diligently:

·Listening more and talking less

·Following more and steering less

·Advocating more and complying less

·Including more and ignoring less

·Collaborating more and commanding less

This sounds like good, old-fashioned therapy to us.

Underneath all of our clinical practices – indeed all helpful interactions – lies a particular kind of conversation. Our field is replete with examples of how professionals should speak with and be with clients. This can be a source of great fascination, from the earliest authors, through Carl Rogers’ core conditions, Berg and de Shazer’s focus on the seemingly simple search for solutions, and beyond. Wampold and Imel (2015) referred to the conversation as “perhaps the ultimate in low technology” (p. ix).

Obviously, not all conversations are helpful, even as they are central to all bona fide forms of psychotherapy (Wampold & Imel, 2015). Indeed, Lilienfeld (2007) has highlighted how some treatments can cause harm. What was central to the Japanese VPOs’ assessment of their failures reflects what has been found in research into the therapeutic alliance (Hubble, Duncan, & Miller, 1999; Duncan, Miller, Wampold, & Hubble, 2010). That is, that the most helpful clinical practice takes place when there is agreement, from the client’s perspective, on the nature of their relationship, the goals of their work, and the means by which they go about it. This view of the working alliance dates back decades (Bordin, 1979), although research has also emphasized the importance of delivering treatment in accordance with strong client values and preferences (e.g., Norcross, 2010). Indeed, importance of the alliance has long been recognized (Orlinsky & Rønnestad, 2005).

These points seem worthwhile in the wake of recent discussions on ATSA’s listserv regarding whether treatment “works” and with whom it is most likely to be effective. It often seems odd that professionals in our field rarely ask their clients about their beliefs as to whether the services they receive are helpful. Perhaps this is due to many professional’s beliefs that asking about what does and doesn’t work in treatment would open the door to discord or attempts at manipulation. Perhaps it’s because many of us couldn’t handle what our clients really think.

Likewise, as professionals we seem hesitant to get into debates about the service user voice evidence-based practices. In a recent conversation on the ATSA listserv a member noted the differences between the American Psychological Association’s definition (“the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences”) and the more stringent standards for empirically supported protocols such as EMDR and DBT. In the end, understanding the treatment experience from the perspective of the client and working to ensure agreement on the goals and tasks of treatment as well as the nature of the working relationship may have as strong an evidence base as any other approach in the helping professions.

The need to understand, process and reflect upon the service user raises the important question - what is an appropriate evidence base? We spend a lot of time discussing the merits of psychometrics, clinical trials, Randomized Control Trails and downplay the importance of qualitative research. The common narrative in the field is about levels of significance and outcome measures, not necessarily about what was said in and about the treatment. Maybe the first think that we need to do, before listening to and acting, is to recognize the service user voice.

Friday, September 9, 2016

A
recent report from the Crown Prosecution Service [CPS] for England
and Wales shows an upturn in reporting, recording, prosecutions
and convictions in sexual harm [including, Rape, Child Sexual Abuse,
Prostitution, Honour based offences, etc.] for the year 14/15 for women and girls. Although
the report indicated that the largest increases were for women and girls as
victims of sexual harm and for males as perpetrators, it does also show that
there was an increase for men and boys as victims as well as for females as
perpetrators too. The data came from the CPS case management system, which
means that the results and analysis were based upon what was recorded by CPS
staff via the existing databases and systems.

The
report signals that:

- The
volume of referral’s to the CPS for Sexual Abuse, Domestic Violence and Rape
decreased by 3.3% to 124,737 compared to 14/15;

- The
volume of individuals charged with Sexual Abuse, Domestic Violence and Rape by
the CPS increased by 0.5% to 86,067 compared to 14/15;

- The
volume of individuals prosecuted by the CPS for Sexual Abuse, Domestic Violence
and Rape increased by 9.8%, to 117,568 defendant’s, from 14/15 to the highest
level ever recorded; and

- The
volume of individuals convicted of Sexual Abuse, Domestic Violence and Rape
also rose by 10.8%, to 87,275, from 14/15 to 87,275 in 15/16, to the highest
level ever recorded.

The
main take-home message from the report is that the volume of prosecutions and
convictions across the violence against women and children spectrum is the
highest that they have been over the last nine years that the CPS has been
recording them in this fashion and that new, as well as relatively new,
offences (e.g., Female Genital Mutilation, Honour Based crimes and revenge porn
offences) have shown increasing referral’s, charges, prosecutions and
convictions. The report highlights, what we have often suspected, that the
rates of sexual harm and violence against women and children do not match the
reality of sexual harm in society. However, it’s important to put these
findings into context as we need to recognise that 15/16 was not necessarily a
peak year for sexual harm, but rather that it is an indication of a turning
tide in society;

- There
seems to be a growing trust in the Criminal Justice System epically the police; the public seems to be more
willing to report crime and seek prosecutions.

- An
increased awareness of violence against women and children in society because
of high profile media cases, the IICSA investigation and a series government reviews (inc,
prostitution, hate crime, etc).

- Updates and changes to crime recording (including,
the recording of new crimes and a change in terminology in existing ones) means
that some offences may have not been recorded previously, or if they had been
recorded they may have been recorded in a different category.

- A
commitment from the CPS to offer more support to victims of
sexual harm, with the former Prime Minister calling sexual abuse a national threat.

- An
increase in funding to understand, prevent and respond to FMG, honour-based
violence and trafficking from the UK government.

This
highlights a commitment from the Criminal Justice System in England & Wales
and UK government to respond to sexual harm, and related offences, resulting in
increased reporting, recording, prosecutions and convictions. The increase
revealed by the CPS report is not surprising given the under-reported nature of
sexual harm and starts to help us understand the nature of these offences in
society; the take-home message seems to be the more we talk, the more we see
and the clearer picture we get. Therefore it’s not so much an increase,
potentially, but rather a reality check and call for more preventive work and
public/societal engagement work to be done.

Friday, September 2, 2016

Trending research demonstrates
low rates of sexual recidivism for nearly all juveniles and most adult sexual offenders. Many studies have been aimed at trying to determine
whether ‘sex offender’ treatment is effective at reducing recidivism. But there is growing evidence that most
sexual offenders will not reoffend, regardless of treatment, and moreover, that
treatment has only a small or moderate effect on recidivism. If treatment isn’t as effective as we want it
to be, what do we do with such ‘inconvenient’ data? We can consider elements of an effective intervention, and uniquely tailor
individual pathways for clients to recover.
When indicated, it should include sex-specific treatment.

A recent, large
meta-analysis by Schmucker and Lösel (2015) reports sexual recidivism of 13.7%
for untreated offenders, and 10.1% for clients who completed treatment - an
absolute reduction in recidivism of 3.6%, and a relative reduction of 26.3%. Previous studies by Lösel and Schmucker (2005),
(2008) showed a slightly stronger, but still low-moderate treatment
effect. Duwe and Goldman (2009) found a
13.4% sexual reoffense rate for treated clients versus 19.5% sexual recidivism
for offenders who did not participate in treatment. Many other studies have found similar results.

Karl Hanson and
colleagues (2014)
confirmed a low rate of reoffending (1%-5%) for low risk sexual offenders, and
a 22% rate of reoffending for high-risk offenders after five years, but then
discovered that after ten years offense-free in the community, high-risk
offenders effectively became low recidivism offenders. Michael Caldwell (2016)
completed the largest meta-analysis to date, which revealed current sexual
recidivism rates for juveniles is likely to be less than 3%. In both studies, if clients reoffended, it
was likely to occur within the first few years after intervention. Authors in both studies were unable to
determine WHY recidivism was low and desistance was stronger over time; yet it seems
that effective treatment might enhance outcomes.

Risk for reoffending,
as part of a psychosexual assessment, seems to have become overly simplified
into essentially three categories: low, medium, and high risk, which then often
determines outcomes: everything from plea agreements, to incarceration,
treatment, and perhaps conditions of supervision or imposition of civil regulations.
So how can we analyze the cost-benefit of interventions to clients, and to
public interests?

Gregory DeClue has
suggested an empirical process from the world of medical treatment might be
helpful to determine the cost-benefit of treatment. Dr. DeClue points to statistical concepts
known as “Number Needed to
Treat” (NNT), and “Number
Needed to Harm” (NNH). Together, NNT and NNH provide an empirical
way to consider, in an aggregate manner, the cost-benefit to “treat” or “not to
treat.” According to DeClue, using data
from Schmucker and Lösel (2015), NNT reveals that only about one person in 28
is likely to not reoffend as the direct result of treatment. That seems like a weak return on the
investment, but more troubling is the counterbalance: to what extent is treatment actually
unwarranted, counterproductive, or indeed harmful to individuals and their
families – known as iatrogenic
consequences?

A meta-analysis by Kim,
Benekos, & Merlo (2016) found “that sex offender treatments can be
considered proven or at least promising.” They also determined that ages of
clients and types of interventions influence the success of treatment. This study also suggests that outpatient
treatment may be more effective than treatment in prison, “If community
treatment is more effective than institutional treatment, then a review of
existing sentencing statutes and policies might be appropriate.” So if treatment
is not the primary change agent, what is?
It might be, broadly, the intervention.

Most individuals
arrested for sexual offending do
not sexually reoffend, and treatment effect alone doesn’t account for low
recidivism rates; so what else might broadly mitigate reoffending? Research indicates that civil regulations
(the registry, residency restrictions, etc.) are not only ineffective,
they might be counterproductive.
More and more, civil regulations are
being challenged
by the judiciary in state and federal courts as not only being ineffective,
but unconstitutional. Caldwell
wrote, “The bulk of available evidence indicates that
the decline in adult and juvenile sexual recidivism rates has occurred,
unrelated to, and perhaps despite, these recent policy trends.” The sex offender registry is especially harmful to juveniles. Birgden and Cucolo (2011)
argue that treatment as management, rather than treatment as rehabilitation,
panders to public policy and puts unwarranted concerns about public safety
ahead of effective treatment. CSOM
promotes a systems
approach to interventions, including effective supervision, and that
recovery is not all about ‘treatment.’

We should be mindful
that reducing risk is not the only aim of treatment, and only tells part of the
story about an effective intervention. And how do we determine what kind of
treatment experiences we should offer? For
example, Levenson and Prescott (2013), discuss many benefits that may be
derived from treatment, resulting in improved outcomes for clients, victims, and
their families - better lives AND safer communities. Indeed, the same authors have published three
studies indicating that people who have sexually abused typically believe their
treatment experiences to be worthwhile (e.g., Levenson & Prescott, 2009). Perhaps one avenue for professionals to
consider is moving beyond treatment interventions that focus on reducing risk
and help people remain at low risk. Another treatment target might be helping clients
adjust to the social consequences of being publically labeled a “sex offender.”
Still another focus of treatment might be “cognitive transformation” –
promoting desistance by helping clients view themselves as having become a
different (better) person.

When recidivism rates
are low, and treatment effect is weak, it raises questions about when sex
offender ‘treatment’ is indicated – effectively begging the question: “to
treat” or “not to treat.” The answers
are only partially informed by risk/recidivism studies. Many questions abound,
including the influence of treatment on the nature, severity, imminence, and
frequency of re-offense, if it does occur. Further, while it makes sense to ask
whether treatment works, we are still in need of research into the effective
components of both treatment and treatment providers. In addition to
psychological factors, we should consider situational factors that might contribute
to re-offending after treatment completion.

How should new data on
the weak effectiveness of ‘treatment’ guide interventions with individual
clients? How should public policies be
reviewed in light of new research? Collectively,
new data, and anecdotal evidence, provides strong evidence that the “sex offender
system” might be mired not just in ‘old research’ about what works in the treatment
and management of sexual offenders, but that public policies are straining
valid concerns for public safety. As a result,
systems are overreaching and over-treating individuals, in large numbers, from
juveniles to the civilly committed. The
consequences to individuals and families, and the costs to public interests, are
incalculable.

Why are so many people
ending up in the “sex offender system”?
Perhaps one reason is a tendency to conflate “seriousness” of a sexual
offense with “dangerousness.” This
results in catching too many individuals in the “sex offender net,” regardless
of “dangerousness” and, out of fear of any
risk of reoffending, the system is reluctant to let them go. In order to avoid any true positives
(predicted to reoffend and does), or false negatives (predicted to NOT reoffend
but does), the system is willing to tolerate a high percentage of false
positives (predicted to reoffend but doesn’t).
Or simply stated, “Better to lock up ten sex offenders than one might
reoffend.” The fallacy is that about nine
out of ten offenders are not likely to sexually reoffend, yet we commit vast,
unwarranted public resources to nine out of ten sexual offenders, as an
unwarranted hedge against possible recidivism.

In the UK, with the
introduction of the transforming
rehabilitation agenda, distinguishing between low and high risk offenders is
becoming more salient in community management.
It distinguishes between sex offenders and non sex offenders, by risk
categories and management. All sex
offenders are now managed by a streamlined probation services, while low/medium
risk non sex offenders are managed by private Community Rehabilitation
Companies (on a payment-by-results scheme).
All high/very high risk offenders are managed by traditional probation. This suggests that the UK government perceives
low risk sex offenders as generally more dangerous than low-risk non sex offenders.

Interestingly, in the
UK (and elsewhere outside the USA) not all sex offenders receive treatment – it is based
on their level of risk and whether or not clients deny their offence. In the UK, it is usually medium, high and
very high risk sex offenders that receive Sex Offender Treatment Programmes (SOTP);
with low risk offenders receiving a form of cognitive skills program. Putting low-risk sex offender in SOTP could
actually make
clients worse and increase their likelihood of offending. Practitioners and
policymakers suggest that we look at alternatives to traditional
SOTP, and Ruth Mann points to a wide-range of psycho-social
treatment interventions. With skepticism
about whether sex offender treatment
works, in the UK, treatment must be evidence-based.

So what are the
takeaways here? One is to avoid the tendency
to measure the success of ‘treatment’ in a dichotomous manner - whether or not
clients reoffend. There is much more to consider in decisions
about treatment, e.g. when is treatment indicated? Should treatment
be compulsory? If so, where should treatment take place (institution
or in the community)? What are the specific treatment targets
to measure progress and determine completion? What kind
of treatment is effective for a particular client? How much
treatment is enough? Principles of Risk-Need-Responsivity
and Good Lives are able to
empirically guide the application of aggregate data and other
research to individual clients.
Sometimes, when empirical evidence suggests treatment is not indicated,
we still need to intervene, but find
the courage to not put clients through unwarranted or lengthy ‘treatment.’

By all indications, a wide-range of interventions seems
to effectively mitigate recidivism, so perhaps rather than focusing on
“does treatment work,” what might be needed is to fine-tune characteristics
of interventions that are demonstrated to be effective with specific types of
clients, e.g. juveniles, low risk, non-contact, females, repeat offenders, etc.
Not all sexual offending is rooted in
sexual deviancy, sexual compulsion, or sexual violence. Sometimes people simply lose their sexual
boundaries, and it’s not likely to happen again. While it may be useful to trace pathways to
sexual offending, not every sexual offender has a sexual offense “cycle.” With half of all sexual assaults occurring
under the influence of alcohol, treatment for chemical abuse or addiction might
be primary.
Not everyone who sexually offends needs sex-specific treatment. A large percentage of adolescent offenders,
and their families, might be well-served by participation in a time-limited
psycho-sexual education program.

Because sexual offending is often more about relationship
violations than sexual violence, interventions might focus much more on managing
social damage, repairing relationships, and restoring families. When there is so much that can be accomplished
by creating a recovery plan that is unique to individuals and their families,
it’s unfortunate that there is so much emphasis placed on “relapse prevention,”
strict compliance with supervision, or criminal enforcement of civil
regulations. Effective interventions can build on the optimism of protective
factors, use positive psychology to build social skills, competency, and
resiliency, and embrace strength-based
principles of Good Lives.

When sexual misconduct occurs, intervention is almost always warranted – ‘treatment’ might not
be. Interventions can be empirically guided
by a client’s Risk-Need-Responsivity and principles of Good Lives, and perhaps by
uniquely tailoring interventions to individual clients, with consideration of
the five “W’s”: who, what, when, where, and why.

Jon Brandt, David Prescott, and Kieran
McCartan

Appreciation to Greg DeClue, Ph.D. and Michael D. Thompson, Psy.D. for contributions
to this blog.

Kieran McCartan, PhD

Chief Blogger

David Prescott, LICSW

Associate blogger

Translate

The Association for the Treatment of Sexual Abusers (http://atsa.com/) is an international, multi-disciplinary organization dedicated to preventing sexual abuse. Through research, education, and shared learning ATSA promotes evidence based practice, public policy and community strategies that lead to the effective assessment, treatment and management of individuals who have sexually abused or are risk to abuse.

The views expressed on this blog are of the bloggers and are not necessarily those of the Association for the Treatment of Sexual Abusers, Sexual Abuse: A Journal of Research & Treatment, or Sage Journals.

Disclaimer

ATSA does not endorse, support, represent or guarantee the completeness, truthfulness, accuracy, or reliability of any Content posted. ATSA does not necessarily or automatically endorse any opinions expressed within this blog. You understand that by reading this blog, you may be exposed to content or opinions that might be offensive, harmful, inaccurate or otherwise inappropriate. Under no circumstances will ATSA be liable in any way for any Content, including, but not limited to, any errors or omissions in any Content, or any loss or damage of any kind incurred as a result of the use of any Content or opinions posted, emailed, transmitted, or otherwise made available via this blog.